Specific nursing care associated with enteral feeding

The nursing care associated with this type of feeding can be considered as follows.

Nasogastric feeding/nasojejunal feeding

Nasogastric insertion/ensuring the correct position

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NG tube insertion: This is normally performed by a registered nurse, dietician or doctor.

Within the clinical area, policies and guidelines should be used to advise on the exact procedures for insertion and checking of the tube position. These should be based on the guidance provided by the National Patient Safety Agency (NPSA, 2005).

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NG tube position: This should be done at the following times (NICE, 2006; NPSA, 2005) on initial placement, before a feed, before giving medication (if the tube is being used), following vomiting or coughing, after tube dislodgement, and if the patient complains of discomfort.

For a very comprehensive step-by-step account of how to insert and check an NG tube, refer to local policies and procedures.

Table6.3Thetypesofenteralfeedandtheirspecificconsiderations. Typeof feedIndicationContraindicationPracticalconsiderations NGfeed•Short-termuseforclientswithuseof stomachandnovomitingoraspiration •Also,impairedswallowing(e.g.stroke), alteredconsciousness,ventilated clients,dysphagia •Forsupplementationofinadequate oralintakes •Psychologicalrequirements,e.g. anorexianervosa

•Obstructionpreventingpassageof tube •Impairedstomachemptyingdueto obstruction •Intestinalobstruction •Intestinalperforationornearby gastrointestinalfistula •Severefacialinjury

•Twomaintypesoftubesmaybeused: Fineboreorwidebore(e.g.Ryles). Normallyafineboretubeisused •CareoftheNGtube.Toinclude: Passingthetube Ensuringcorrectposition Regularcheckingoftubeposition Feedadministration •Complications.Theseincluderemoval bythepatientduetoconfusionoron purposeasameansofwithdrawing consent. Ulceration/narrowing/stricturesof theoesophagus.Thisisunusualwhen fineboretubesareused.Diarrhoea NJfeed•Short-termuseforclientswhose stomachneedstobebypassedand wherethereisnovomiting •Inclientswithahighriskofaspiration •Pancreatitis

•AsperNGfeeding(seeabove)•Twomaintypesoftubesmaybeused: Singlelumen(canbeplacedwithor withoutanendoscope)ordouble lumen(needsspecialistplacement) •CareoftheNJtube.Toinclude: Passingthetube(normallydone endoscopically) Ensuringcorrectposition(normally doneunderXray) Regularcheckingoftubeposition Feedadministration •Complications.AsperNGfeeding(see above) (Continued)

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Table6.3(Continued) Typeof feedIndicationContraindicationPracticalconsiderations PEG/PEJ feeds•Forlongertermfeedingmorethan4 weeks. •Usedparticularlyincerebrovascular accidents(stroke),headinjury, multiplesclerosis,motorneurone disease,severephysicalandlearning disabilities

•Ascites,severeobesity,bloodclotting abnormalities,oesophagealorgastric varices(varicoseveinsinthe gastrointestinaltract),gastric ulcerationormalignancy.

•CareofthePEG/PEJtube.Toinclude: Insertionofthetube(performed endoscopically) Checkingandmanagementof insertionsite Feedadministration •Complications.Peritonitis,aspiration, infectionofthesite,haemorrhage, tubeblockage,deathoftissue (necrosis)aroundthesitedueto pressurefromthetubelimitingthe localbloodsupply. NG,nasogastric;NJ,nasojejunal;PEJ/PEG,percutaneousendoscopicallyplacedgastrostomyorjejunostomy.

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Nasojejunal insertion/ensuring the correct position

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NJ tube insertion: This is normally performed by staff using endoscopy and can be checked using X-ray.

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NJ tube position: To avoid the displacement of the tube, it must be securely fixed to the nose or cheek. A permanent mark should be made at the point where the tube leaves the nose. The position should be checked before commencing a feed. If there are signs that the tube may have moved, report this to the appropriate registered practitioner (registered nurse, dietician, doctor or nutritional nurse specialist).Do not commence a feed until the position is confirmed.

NG/NJ feed administration

A registered nurse will have ultimate responsibility for the management of the feed.

However, other staff may provide aspects of care after receiving the appropriate training.

The guidelines below outline how to deliver an NG or NJ feed and have been adapted from Bowling (2004), NICE (2006) and NPSA (2005). However, always refer to local policies and procedures when delivering this type of care.

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Before any feed commences the position of the tube must be checked according to policy and procedures (see above).Do not commence a feed until the position of the tube is confirmed. Remember there is a significant risk of pulmonary aspiration (feed entering the lungs) if the tube is misplaced.

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Wash hands thoroughly and use a clean apron before beginning the procedure. Hy- giene is extremely important when dealing with these feeds. Nasojejunal feeds carry a greater risk of infection since the acid environment of the stomach is bypassed. This acid environment would normally act as a barrier to infection.

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Position the client at a 30–45^◦ upright angle unless their medical condition does not allow this (e.g. spinal injury). Keep upright for 1 hour after the feed to avoid aspiration due to reflux.

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For NG feeding, two methods of feeding may be used:Pump feeding, where an infusion pump continuously delivers the feed at a rate of approximately 100 mL/hour (this is determined by the dietician); or gravity feeding, where a 50–60-mL syringe containing feed is attached to the giving set. This is held higher than the client and allowed to drain into the NG tube.

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For NJ feeding, a pump feed will be used. The initial rate will be slower since the small intestine cannot hold as much fluid and it will be increased slowly over time

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Feeding duration will vary according to the method of delivery and the requirements of the client. Normally, a break in feeding is given to clients on NG feeds. However, NJ feeds can continue over the full 24 hours.

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Administer the feed as prescribed and documented by the dietician. Ensure that the correct feed is given at the correct time and rate of delivery.

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To prevent blockage the NG tube should be flushed with 50 mL cooled, boiled (at home) or sterile water (in the acute setting) pre- and post-feeds and medication. The NJ tube should be flushed every 6 hours with 30 mL sterile water using a 50-mL syringe.

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Record the amount of feed given.

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Report and record any complications immediately.

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Continue nutritional monitoring and screening to help evaluate the effectiveness of the feeding regime.

Percutaneous endoscopically placed gastrostomy or jejunostomy feeding

This type of feeding is used with clients who require enteral feeding for more than 4 weeks. The tube requires surgical placement using endoscopy. As with the other types of enteral feeding, the responsibility for the client’s care will remain with the registered nurse. However other staff who have been properly trained may be involved in some aspects of care.

Care following a PEG/PEJ insertion

Initial care following insertion is based on monitoring the client’s physiological status following an invasive surgical procedure. Any changes in the client’s condition can then be quickly acted upon and further complications prevented.

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Following the procedure, monitor and record temperature, pulse, respirations and blood pressure half hourly for 4 hours and then hourly for 2 hours. Immediately report to the Registered nurse any changes in the client’s observations.

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Report any signs or complaints of pain to the registered nurse. Analgesia can then be given.

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The client will remain nil by mouth and nil by tube for 4 hours post-procedure.

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Inspect the insertion site for blood or serous fluid leakage. Immediately report any leakage or continuous bleeding to a registered nurse or doctor since a further dressing or suturing may be required.

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After 4 hours the tube may be flushed with sterile water.

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The dietician will determine the full feeding regimen (course of treatment).

PEG/PEJ feed administration

The principles of care related to this type of feeding are similar to those related to NG and NJ feeding. However particular care is needed of the insertion site to prevent infection.

If the site requires cleaning, full aseptic technique must be used. After 5–6 weeks (when a fibrous tract develops through the abdominal wall) the original tube may be removed and a more compact skin level gastrostomy ‘button’ tube is inserted. This offers a neat, easily managed tube for longer term feeding. When this type of feeding is no longer needed, the tube is removed via endoscopy.

The ongoing care of PEG and PEJ feeding is more specialised than that of nasogastric and nasojejunal feeding. To examine these in more depth, please refer to local policies and procedures.